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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 1 - Clinical Principles


Operative care principles

The woman is the primary focus of the physician/midwife and nurse during any procedure. The surgical or scrub nurse has her attention focused on the procedure and the needs of the physician/midwife performing the procedure.

 

PRE-OPERATIVE CARE PRINCIPLES

Preparing the operating theatre

Ensure that:

  • the operating theatre is clean (it should be cleaned after every procedure);

  • necessary supplies and equipment are available, including drugs and an oxygen cylinder;

  • emergency equipment is available and in working order;

  • there are adequate supply of theatre dress for the anticipated members of the surgical team;

  • clean linens are available;

  • sterile supplies (gloves, gauze, instruments) are available and not beyond expiry date.

 

Preparing the woman for a surgical procedure

- Check for any possible allergies;

- Ensure that the woman has received the complete antitetanus regimen and give one dose of tetanus vaccine, if necessary.

  • Send a blood sample for haemoglobin or haematocrit and type and screen. Order blood for possible transfusion. Do not delay transfusion if needed.

  • Wash the area around the proposed incision site with soap and water, if necessary.

  • Do not shave the woman’s pubic hair as this increases the risk of wound infection. The hair may be trimmed, if necessary.

  • Monitor and record vital signs (blood pressure, pulse, respiratory rate and temperature).

  • Administer premedication appropriate for the anaesthesia used.

  • Give an antacid (sodium citrate 0.3% 30 mL or magnesium trisilicate 300 mg) to reduce stomach acid in case there is aspiration.

  • Catheterize the bladder if necessary and monitor urine output.

  • Ensure that all relevant information is passed on to other members of the team (doctor/midwife, nurse, anaesthetist, assistant and others).

Intra-operative care principles

Position

Place the woman in a position appropriate for the procedure to allow:

  • optimum exposure of the operative site;

  • access for the anaesthetist;

  • access for the nurse to take vital signs and monitor IV drugs and infusions;

  • safety of the woman by preventing injuries and maintaining circulation;

  • maintenance of the woman’s dignity and modesty.

Note: If the woman has not delivered, have the operating table tilted to the left or place a pillow or folded linen under her right lower back to decrease supine hypotension syndrome.

 

Surgical handscrub

  • Remove all jewelry.

  • Hold hands above the level of the elbow, wet hands thoroughly and apply soap (preferably an iodophre, e.g. betadine).

  • Begin at the fingertips and lather and wash, using a circular motion:

- Wash between all fingers;

- Move from the fingertips to the elbows of one hand and then repeat for the second hand.

- Wash for three to five minutes

  • Rinse each arm separately, fingertips first, holding hands above the level of the elbows.

  • Dry hands with a clean or disposable towel, wiping from the fingertips to the elbows, or allow hands to air dry.

  • Ensure that scrubbed hands do not come into contact with objects (e.g. equipment, protective gown) that are not high-level disinfected or sterile. If the hands touch a contaminated surface, repeat surgical handscrub.

Preparing the incision site

  • Prepare the skin with an antiseptic (e.g. iodophors, chlorhexidine):

- Apply antiseptic solution three times to the incision site using a high-level disinfected ring forceps and cotton or gauze swab. If the swab is held with a gloved hand, do not contaminate the glove by touching unprepared skin;

- Begin at the proposed incision site and work outward in a circular motion away from the incision site;

- At the edge of the sterile field discard the swab.

  • Never go back to the middle of the prepared area with the same swab. Keep your arms and elbows high and surgical dress away from the surgical field.

  • Drape the woman immediately after the area is prepared to avoid contamination:

- If the drape has a window, place the window directly over the incision site first.

- Unfold the drape away from the incision site to avoid contamination.

Monitoring

Monitor the woman’s condition regularly throughout the procedure.

  • Monitor vital signs (blood pressure, pulse, respiratory rate), level of consciousness and blood loss. 

  • Record the findings on a monitoring sheet to allow quick recognition if the woman’s condition deteriorates.

  • Maintain adequate hydration throughout surgery.

Managing pain

Maintain adequate pain management throughout the procedure. Women who are comfortable during a procedure are less likely to move and cause injury to themselves.  Pain management can include:

  • emotional support and encouragement;

  • local anaesthesia;

  • regional anaesthesia (e.g. spinal);

  • general anaesthesia.

Antibiotics

Making the incision

  • Make the incision only as large as necessary for the procedure.

  • Make the incision with great care and proceed one layer at a time.

Handling tissue

  • Handle tissue gently.

  • When using clamps, close the clamp only one ratchet (click), when possible. This will minimize discomfort and reduce the amount of dead tissue that remains behind at the end
    of the procedure, thus decreasing the risk of infection.

Haemostasis

  • Ensure haemostasis throughout the procedure.

  • Women with obstetrical complications often have anaemia. Therefore, keep blood loss to a minimum.

Instruments and sharps

  • Start and finish the procedure with a count of instruments, sharps and sponges:

- Perform the count every time a body cavity (e.g. uterus) is closed;

- Document in the woman’s record that the surgical counts were correct. 

- Use a pan such as a kidney basin to carry and pass sharp items and pass suture needles on a needle holder;

- Alternatively, pass the instrument with the handle, rather than the sharp end, pointing toward the receiver.

Drainage

  • Always leave an abdominal drain in place if:

- bleeding persists after hysterectomy;

- a clotting disorder is suspected;

- infection is present or suspected.

  • A closed drainage system can be used or a corrugated rubber drain can be placed through the abdominal wall or pouch of Douglas.

  • Remove the drain once the infection has cleared or when no pus or blood-stained fluid has drained for 48 hours.

Suture

  • Select the appropriate type and size of suture for the tissue (Table C-7). Sizes are reported by a number of “0”s:

- Smaller suture has a greater number of “0”s [e.g. 000 (3-0) suture is smaller than 00 (2-0) suture]; suture labeled as “1” is larger in diameter than “0” suture. 

- A suture that is too small will be weak and may break easily; a suture that is too large in diameter will tear through tissue.

  • Refer to the appropriate section for the recommended size and type of suture for a procedure.

Table C-7

Recommended suture types

Suture Type

Tissue

Recommended Number

 of Knots

Plain catgut

Fallopian tube

3a

Chromic catgut

Muscle, fascia

3a

Polyglycolic

Muscle, fascia, skin

4

Nylon

Skin

6

Silk

Skin, bowel

3a

 

a Because these are natural sutures, do not use more than three knots because this will abrade the suture and weaken the knot.

 

Dressing

At the conclusion of surgery, cover the surgical wound with a sterile dressing.

Postoperative care principles

Initial care

- Place the woman in the recovery position:

- Position the woman on her side with her head slightly extended to ensure a clear airway;

- Place the upper arm in front of the body for easy access to check blood pressure;

- Place legs so that they are flexed, with the upper leg slightly more flexed than the lower to maintain balance.

  • Assess the woman’s condition immediately after the procedure:

- Check vital signs (blood pressure, pulse, respiratory rate) and temperature every 15 minutes during the first hour, then every 30 minutes for the next hour.

- Assess the level of consciousness every 15 minutes until the woman is alert.

Note: Ensure the woman has constant supervision until conscious.

  • Ensure a clear airway and adequate ventilation.

  • Transfuse if necessary.

  • If vital signs become unstable or if the haematocrit continues to fall despite transfusion, quickly return to the operating theatre because bleeding may be the cause.

 

GASTROINTESTINAL FUNCTION

Gastrointestinal function typically returns rapidly for obstetrical patients. For most uncomplicated procedures, bowel function should be normal within 12 hours of surgery.

  • If the surgical procedure was uncomplicated, give the woman a liquid diet.

  • If there were signs of infection, or if the caesarean was for obstructed labour or uterine rupture, wait until bowel sounds are heard before giving liquids.

  • When the woman is passing gas, begin giving her solid food.

  • If the woman is receiving IV fluids, they should be continued until she is taking liquids well. 

  • If you anticipate that the woman will receive IV fluids for 48 hours or more, infuse a balanced electrolyte solution (e.g. potassium chloride 1.5 g in 1 L IV fluids).

  • If the woman receives IV fluids for more than 48 hours, monitor electrolytes every 48 hours. Prolonged infusion of IV fluids can alter electrolyte balance. 

  • Ensure the woman is eating a regular diet prior to discharge from hospital.

Dressing and wound care

The dressing provides a protective barrier against infection while a healing process known as “re-epithelialization” occurs. Keep the dressing on the wound for the first day after surgery to protect against infection while re-epithelialization occurs. Thereafter, a dressing is not necessary. 

  • If blood or fluid is leaking through the initial dressing, do not change the dressing:

- Reinforce the dressing;

- Monitor the amount of blood/fluid lost by outlining the blood stain on the dressing with a pen;

- If bleeding increases or the blood stain covers half the dressing or more, remove the dressing and inspect the wound. Replace with another sterile dressing.

  • If the dressing comes loose, reinforce with more tape rather than removing the dressing. This will help maintain the sterility of the dressing and reduce the risk of wound infection.

  • Change the dressing using sterile technique.

  • The wound should be clean and dry, without evidence of infection or seroma prior to the woman’s discharge from the hospital. 

Analgesia

Adequate postoperative pain control is important. A woman who is in severe pain does not recover well.

Note: Avoid over sedation as this will limit mobility, which is important during the postoperative period.

Bladder care

A urinary catheter ay be required for some procedures. Early catheter removal decreases the chance of infection and encourages the woman to walk. 

  • If the urine is clear, remove the catheter 8 hours after surgery or after the first postoperative night.

  • If the urine is not clear, leave the catheter in place until the urine is clear.

  • Wait 48 hours after surgery before removing the catheter if there was:

- uterine rupture;

- prolonged or obstructed labour;

- massive perineal oedema;

- puerperal sepsis with pelvic peritonitis.

Note: Ensure that the urine is clear before removing the catheter.

  • If the bladder was injured (either from uterine rupture or during caesarean section or laparotomy):

- Leave the catheter in place for a minimum of 7 days and until the urine is clear;

- If the woman is not currently receiving antibiotics, give nitrofurantoin 100 mg by mouth once daily until the catheter is removed, for prophylaxis against cystitis.

Antibiotics

Suture removal

Major support for abdominal incisions comes from the closure of the fascial layer. Remove skin sutures 5 days after surgery.

Fever

Ambulation

Ambulation enhances circulation, encourages deep breathing and stimulates return of normal gastrointestinal function. Encourage foot and leg exercises and mobilize as soon as possible, usually within 24 hours.

Top of page

Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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